Provider Demographics
NPI:1336585892
Name:SPARKS, MARY EMILY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EMILY
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 HOMESTEAD LN
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-9749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35229-0001
Practice Address - Country:US
Practice Address - Phone:205-726-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS10683390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program